Healthcare Provider Details

I. General information

NPI: 1386161289
Provider Name (Legal Business Name): CHILDREN' S COUNTRY HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14643 NE 166TH ST
WOODINVILLE WA
98072-9013
US

IV. Provider business mailing address

14643 NE 166TH ST
WOODINVILLE WA
98072-9013
US

V. Phone/Fax

Practice location:
  • Phone: 425-806-9453
  • Fax: 425-485-1527
Mailing address:
  • Phone: 425-806-9453
  • Fax: 425-485-1527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberIHS.FS.00000253
License Number StateWA

VIII. Authorized Official

Name: MS. DIANE KOLB
Title or Position: EXECUTIVE DIRECTOR
Credential: RD,CD
Phone: 425-806-9453